Thiamine-Responsive Megaloblastic Anaemia With Hypothyroidism, A Puzzling Association

Background

Thiamine-responsive megaloblastic anaemia (TRMA) is characterized by the classic trio of diabetes mellitus, sensorineural hearing loss, and megaloblastic anaemia, typically emerging subtly between infancy and adolescence. Administration of high-dose thiamine often yields improvements in anaemia and occasionally in diabetes. Uncommon manifestations include optic atrophy, congenital heart defects, short stature, and stroke. In this specific case, a 5-year-old diagnosed with insulin-dependent diabetes mellitus (IDDM) since the age of one presented with symptoms such as polyuria, fever, and vomiting, revealing an HbA1c of 10.64. Further examinations disclosed compromised hearing and vision. A negative antibody workup and a thyroid profile indicating hypothyroidism prompted additional investigations, including Brainstem Evoked Response Audiometry (BERA) and retinal examination, confirming bilateral sensorineural hearing loss and maculopathy, respectively. A comprehensive blood count unveiled megaloblastic anaemia. Genetic profiling confirmed a homozygous mutation in the SLC19A2 gene, thus diagnosing TRMA. An early diagnosis, coupled with genetic confirmation, enables timely intervention, with patients responding positively to high-dose thiamine. Genetic counselling plays a pivotal role in enlightening families about the disease and its inheritance patterns, fostering awareness and understanding.

Pancytopenia in celiac disease-A case series of 20 children

Pancytopenia in children with celiac disease (CeD) is postulated to be due to nutritional deficiency such as vitamin B12, folate and copper or an autoimmune process resulting in aplastic anemia with hypoplastic marrow. In the present case series, we report the profile and explore the etiology of pancytopenia among children with CeD. There are only a few case reports of pancytopenia in children with CeD. We enrolled newly diagnosed cases of CeD and pancytopenia presenting in the celiac disease clinic over three years. Detailed evaluation was carried out for the cause of pancytopenia. We followed up on the cases for compliance and response to gluten-free diet at three months, six months and 12 months. Twenty patients were eligible for inclusion. They were divided into two groups: one with aplastic anemia with hypoplastic marrow labeled as Gp CeD-AA and the other with megaloblastic/nutritional anemia labeled as Gp CeD-MA. Patients in Gp CeD-MA presented with classical symptoms of CeD as recurrent diarrhea, abdomen distension, pallor and poor weight gain. They had none or just one transfusion requirement and had an early and complete recovery from pancytopenia. Patients in Gp CeD-AA presented with atypical symptoms such as epistaxis, short stature, fever, pallor and weakness. They had a multiple blood transfusion requirement and had delayed and partial recovery from pancytopenia. Pancytopenia is not a disease in itself but is the presentation of an underlying disease. It can occur due to various coexisting disorders in children with CeD, which can be as simple as nutritional deficiencies to as complex as an autoimmune process or malignancy. CeD should be included in the differential diagnosis of aplastic anemia as CeD and aplastic anemia both have a similar pathological process involving T cell destruction of tissues.

Diabetes Out-of-the-Box: Diabetes Mellitus and Impairment in Hearing and Vision

PURPOSEOF REVIEW

This review aims to provide an update on the etiologies of diabetes that are due to genetic disorders and that co-occur with impaired hearing or vision and to compare them. The potential mechanisms, including novel treatments, will be detailed.

RECENT FINDINGS

Wolfram syndrome, Kearns-Sayre syndrome, thiamine-responsive megaloblastic anemia, and maternally inherited diabetes and deafness are genetic disorders characterized by diabetes, impaired hearing, and vision. They differ in mode of inheritance, age at presentation, and the involvement of other organs; they are often misdiagnosed as type 1 or type 2 diabetes. Suspicion of a genetic diabetes syndrome should be raised when pancreatic autoantibodies are negative, other organs are involved, and family history includes diabetes. Correct diagnosis of the various syndromes is important for tailoring the most advanced treatment, preventing disease progression, and enabling proper genetic counseling.

[Vitamin B12 deficiency in an infant child of a mother with pernicious anemia]

INTRODUCTION

In infants, vitamin B12 deficiency is mainly due to nutritional deficiencies related to maternal deficit. Most cases of maternal deficiencies are associated with vegetarian diets. Pernicious anemia is an au toimmune disease that affects the absorption of this vitamin. Although it is less common than nutri tional deficiency, is also an important cause of maternal deficiency.

OBJECTIVE

to report a case of an infant with vitB12 deficiency, secondary to pernicious anemia in his mother, and to review the most important aspects of this disease in childhood.

CLINICAL CASE

Nine months-old male infant, without pathological perinatal history, exclusively breastfed, with persistent rejection of solid food from 6 months of age. One month before hospitalization, he progressively presented hyporesponsiveness, with fluctuating state of alertness, regression of motor development milestones, and vomiting. The blood count showed macrocytic anemia and neutropenia. Vitamin B12 deficiency was confirmed in the patient. He received treatment with intramuscular vitamin B12 with good clinical and laboratory response. Maternal B12 deficiency was confirmed as the cause of the infant's deficiency. Since the mother reported no dietary restrictions, anti-intrinsic factor and anti-parietal cell antibodies were measured, leading to the diagnosis of pernicious anemia.

CONCLUSIONS

Early recognition is essential to prevent the development of potentially irreversible neurological damage. Maternal pernicious ane mia should be considered in children with megaloblastic anemia, especially in those whose mothers do not follow vegetarian diets.

Absolute Neutrophil Count in Cases of Pancytopenia

Pancytopenia is a common cause of hematological consultation. Common underlying causes include vitamin deficiency (vitamin B12, folic acid), drugs (hydroxyurea, phenytoin, methotrexate), and bone marrow failure syndrome. Aplastic anemia is one of the rarest hematological diseases and presents as pancytopenia. However, it is the most sinister one and is a hematological emergency that needs urgent medical attention. Absolute neutrophil count (ANC) is a measure of disease severity and is expected to be low in patients with pancytopenia of any cause. Aim & Objective: We aimed to analyze the absolute neutrophil count (ANC) level in patients presenting with pancytopenia. Material & Method: This prospective, observational study was conducted at a tertiary care hospital in northern India. We included patients with pancytopenia diagnosed at our center or reported to our center for therapy. ANC was measured before starting therapy. Observation: One hundred twenty-seven patients were included in this study. After evaluation, megaloblastic anemia was the commonest underlying cause in 42 (33%) patients followed by myelodysplastic syndrome in 31 (24.4%) patients. Twenty-three (18.1%) patients having pancytopenia were diagnosed with aplastic anemia. Other causes included leukemia, paroxysmal nocturnal hemoglobinuria and drugs. The median age was 37 years (range 18-75 years), and 67 (52.75%) were male. The mean hemoglobin was 5.5 g/dL (95% CI ±1.9). The median WBC was 2570/cmm (300-3130) and the median platelet was 36000/cmm (2000-92000). The median ANC in patients with aplastic anemia was 594/cmm (range 25- 3850). When compared, the ANC level was significantly lower in aplastic anemia than other causes of pancytopenia (p<0.001). Conclusion: On univariate and multivariate analysis ANC was significantly lower at baseline in patients of aplastic anemia. A longer follow-up of the patients will be required to assess the value of ANC in predicting response to therapy.

LONG-TERM MULTIMODAL IMAGING OF OCULAR FINDINGS ASSOCIATED WITH THIAMINE-RESPONSIVE MEGALOBLASTIC ANEMIA

PURPOSE

To report on 5-year multimodal imaging of ocular findings in a patient with thiamine-responsive megaloblastic anemia.

METHODS

Observational case report.

RESULTS

A 20-year-old-man with a history of thiamine-responsive megaloblastic anemia demonstrated a symmetric bull's eye maculopathy. Spectral domain optical coherence tomography revealed disruption of the parafoveal ellipsoid zone, fundus autofluorescence demonstrated foveal hypoautofluorescence, and full-field electroretinogram testing revealed a decreased photopic and scotopic response consistent with cone-rod dystrophy. His best-corrected visual acuity remained stable over 5 years at 20/50 in the right eye and 20/40 in the left eye, and visual field testing remained stable over time.

CONCLUSION

Ocular manifestations in thiamine-responsive megaloblastic anemia are uncommon and variable. In this case, multimodal imaging and electroretinogram findings are consistent with cone-rod degeneration. The patient is taking daily thiamine supplementation, and visual acuity, funduscopic examination, spectral domain optical coherence tomography, and autofluorescence remained stable over a 5-year period.

Clinicohematological Study of Pancytopenia in a Tertiary Care Hospital of Western Region of Nepal

INTRODUCTION

Pancytopenia is a relatively common hematological entity and is a manifestation of many illnesses which can be life threatening at times. The severity of pancytopenia and the underlying pathology determine the management and prognosis. This study was conducted to evaluate hematological and bone marrow findings in patients presenting with pancytopenia.

METHODS

A prospective observational study was conducted in Department of Pathology, Manipal College of Medical Sciences, Pokhara from January 2011 to December 2016. Clinical and hematological parameters including bone marrow aspiration and biopsy were evaluated in all patients who presented with pancytopenia.

RESULTS

Among 138 cases studied, patients' age ranged from 2 to 82 years with a mean age of 43.95 years, and there was male predominance. Most of the patients presented with generalized weakness, pallor, dypnoea and fever. Hypoplastic marrow was seen in 38 (27.5%) cases, followed by 26 (18.8%) cases of megaloblastic anemia and 19 (13.76%) cases of acute leukemia. Other findings included one case each of hemophagocyosis, leishmaniasis, plasmodium vivex malaria and metastatic carcinoma.

CONCLUSIONS

This study highlights that pancytopenia is a common hematological problem and that the study of detailed primary hematological investigations along with bone marrow study in patients with pancytopenia will help to identify the cause for further planning and management.

Micronutrient deficiencies in patients with chronic atrophic autoimmune gastritis: A review

Chronic atrophic autoimmune gastritis (CAAG) is an organ-specific autoimmune disease characterized by an immune response, which is directed towards the parietal cells and intrinsic factor of the gastric body and fundus and leads to hypochlorhydria, hypergastrinemia and inadequate production of the intrinsic factor. As a result, the stomach’s secretion of essential substances, such as hydrochloric acid and intrinsic factor, is reduced, leading to digestive impairments. The most common is vitamin B12 deficiency, which results in a megaloblastic anemia and iron malabsorption, leading to iron deficiency anemia. However, in the last years the deficiency of several other vitamins and micronutrients, such as vitamin C, vitamin D, folic acid and calcium, has been increasingly described in patients with CAAG. In addition the occurrence of multiple vitamin deficiencies may lead to severe hematological, neurological and skeletal manifestations in CAAG patients and highlights the importance of an integrated evaluation of these patients. Nevertheless, the nutritional deficiencies in CAAG are largely understudied. We have investigated the frequency and associated features of nutritional deficiencies in CAAG in order to focus on any deficit that may be clinically significant, but relatively easy to correct. This descriptive review updates and summarizes the literature on different nutrient deficiencies in CAAG in order to optimize the treatment and the follow-up of patients affected with CAAG.

Hepatitis B Leading to Megaloblastic Anemia and Catastrophic Peripheral Thrombocytopenia

Hepatitis B virus (HBV) typically causes chronic hepatitis, cirrhosis, and hepatocellular carcinoma. It is associated with a variety of extrahepatic complications. We herein, present a rare extrahepatic complication of HBV infection. A 32-year man presented with melena, bleeding from gums and fever. Peripheral blood examination revealed anemia, macrocytosis and severe thrombocytopenia. His hepatitis B surface antigen (HBsAg) was positive but deoxyribonucleic acid (HBV DNA) by polymerase chain reaction (PCR) was negative. Other hepatitis, human immune deficiency virus (HIV), dengue, and autoimmune serology were negative. Bone marrow examination revealed megaloblastic erythropoiesis. There was mild to moderate reduction of megakaryocytes in bone marrow, which was not compatible with severe peripheral thrombocytopenia. His response to cyanocobalamin and folic acid was remarkable for myeloid cell lines and moderate for erythroid cell lines, but poor to platelet counts. Platelet counts gradually improved to safe limits with eltrombopag, likely reflecting autoimmune pathogenesis for thrombocytopenia. This case report highlights multiple targets of HBV infection with associated multiple pathogenetic mechanisms.

Natural history of premacular hemorrhage due to severe acute anemia: clinical and anatomical features in two untreated patients

Premacular retrohyaloid hemorrhage is a rare complication of acute severe anemia. The authors report two cases of premacular hemorrhage in which no treatment other than clinical and spectral-domain optical coherence tomography observation was performed. The natural history of this condition reveals that complete clinical resolution is not accompanied by full anatomical restoration. [Ophthalmic Surg Lasers Imaging Retina. 2014;45:E5-E7.].

The role of Helicobacter pylori infection in hematological disorders

Helicobacter pylori (H. pylori) is a Gram-negative spiral bacterium, classified as a carcinogen of class I, according to the World Health Organization (WHO). The infection is a major cause of gastritis, gastric and duodenal ulcer disease and increases the risk of gastric cancer. It has been implicated in the pathogenesis of several gastrointestinal, systemic or hematological diseases. The present review aims in deciphering the role of the bacterium in hematological disorders, increasing the awareness of gastroenterologists, hematologists and internal medicine practitioners, regarding the bacterium-associated hematological diseases. The efficacy of H. pylori eradication in increasing the platelet count in adult patients with primary immune thrombocytopenia (ITP) has been confirmed, linking the infection with the disease. Moreover, as the bacterium causes iron deficiency anemia (IDA) by several mechanisms, recent guidelines indicate H. pylori infection (Hp-I) to be sought in IDA patients if histology is negative and to be eradicated if present. Furthermore, it has been widely recognized that anti-H. pylori treatment causes regression of the low-grade B-cell gastric MALT lymphomas. Despite the well established associations of Hp-I with the aforementioned hematological disorders, we highlight the possible role of the infection to other hematological diseases or conditions such as non-Hodgkin lymphomas of the stomach, monoclonal gammopathy of undetermined significance, megaloblastic anemia and myelodysplastic syndromes. We finally underline the elevated risk of childhood leukemia and of hemorrhage in patients with coagulation disorders, due to the infection.

Tremors and thrombocytosis during treatment of megaloblastic anaemia

In developing countries, a deficiency of cobalamine and folate contributes significantly to megaloblastic anaemia. Neurological observations in infants and young children with megaloblastic anaemia have included hypotonia, developmental regression, tremors and other abnormal movements. Following therapy with vitamin B12, coarse tremors occurred in six of 51 patients (12%) with megaloblastic anaemia. The tremors, which were noticed initially in the hands and feet, gradually became generalised and disappeared during sleep. They subsided within 5-11 days. Thirteen of 25 (52%) patients developed thrombocytosis between day 3 and week 5 of follow-up. In one child, the platelet count increased to >1300 x 10(9)/L. The importance of recognising these clinical findings during treatment of megaloblastic anaemia is emphasised.

Diphyllobothrium pacificum infection is seldom associated with megaloblastic anemia

Twenty cases of Dyphillobothrium pacificum (fish tapeworm) infections were prospectively studied to determine whether this tapeworm is associated with megaloblastic anemia, as commonly reported for D. latum infections. The most frequent symptoms were fatigue and mild abdominal pain, which were identified in approximately 66.6% of the 18 patients interviewed. Fourteen patients received treatment with niclosamide and all were cured. The other six patients spontaneously eliminated the tapeworms. One patient, who also had chronic diabetes and gastric atrophy, had low vitamin B12 levels and megaloblastic anemia. In all other patients, including three other patients with anemia, baseline vitamin B12 levels were in the reference range and did not significantly change when re-assessed three months later. Unlike D. latum, infection with D. pacificum is seldom associated with megaloblastic anemia or vitamin B12 deficit.

Frequency and characterisation of pancytopenia in megaloblastic anaemia

BACKGROUND

A wide variety of clinical conditions, that primarily or secondarily affect the bone-marrow may present with pancytopenia, one of such conditions is megaloblastic anaemia. The purpose of this study was to determine the frequency and nature of pancytopenia in megaloblastic anaemia.

METHODS

This was a prospective, cross-sectional descriptive study conducted in Medical Units, Ayub Teaching Hospital, Abbottabad, Pakistan during July 2010-January 2011. Total 90 patients were included in this study. Data were collected including history, clinical examination, haemoglobin level, mean cell volume, bone marrow examination and peripheral smear examination.

RESULTS

Of total 90 patients, 54 were male and 36 were female. Mean age was 28 +/- 15.84 years. Common presenting features were weakness, fever and bleeding manifestations. Pancytopenia was present in 63 (70%) patients. Most common presenting feature related to anaemia was weakness (80%). Bleeding manifestations, related to low platelet count were found in 35 (39%) patients. Physical Examination findings were: pallor (100%), splenomegaly (33%), bleeding manifestations (25%), hepatomegaly (17%), and hepatosplenomegaly (19%). Mean peripheral blood findings of the study population included haemoglobin level (6.25 g/dL), total leukocyte count (2818.7/microL), platelet count (44040/uL), and reticulocyte count (1.7%). Mean values for red cells indices included red blood cells count (2.6 million/uL), mean corpuscular volume (114.3 fL), mean corpuscular haemoglobin (27.3 pg) and mean corpuscular haemoglobin concentration (31.8 g/dL).

CONCLUSIONS

In megaloblastic anaemia, pancytopenia is a common and important clinical and haematological problem. Patients should be properly investigated for pancytopenia and its causes because many of them are completely curable while others are manageable. This will help to reduce patients' suffering, improve quality of life and prolong survival.

A cross-sectional study of the clinical profile and aetiological spectrum of pancytopenia in a tertiary care centre

INTRODUCTION

Pancytopenia is a common haematological problem. It is suspected when a patient presents with anaemia, prolonged fever and a bleeding tendency. Pancytopenia has multiple causes, but the frequency of these causes has been reported in a limited number of studies. The present study was conducted to assess the aetiological pattern, clinical profile and bone marrow morphology of pancytopenia patients.

METHODS

A total of 111 adult pancytopenia patients aged 13 to 65 years were studied during a one-year period to determine their clinical features, peripheral blood pictures and bone marrow morphologies. The aetiological pattern was assessed through the relevant investigations in the respective patients.

RESULTS

45.95 percent of the pancytopenic patients had a hypocellular marrow, while 54.05 percent had normocellular or hypercellular marrow. Idiopathic aplastic anaemia (20.72 percent) was the commonest cause of pancytopenia, followed by hypersplenism due to chronic liver disease (11.71 percent). Other important causes were kala-azar (nine percent), megaloblastic anaemia, systemic lupus erythematosus (SLE), infections and drug inducement. Infections such as kala-azar, falciparum malaria and enteric fever, megaloblastic anaemia as well as SLE were found to be treatable and reversible causes of pancytopenia.

CONCLUSION

As a large number of pancytopenic patients have a reversible aetiology, early and proper diagnosis may be life-saving.

Orotic aciduria and uridine monophosphate synthase: a reappraisal

Three subtypes of hereditary orotic aciduria are described in the literature, all related to deficiencies in uridine monophosphate synthase, the multifunctional enzyme that contains both orotate: pyrophosphoryl transferase and orotidine monophosphate decarboxylase activities. The type of enzyme defect present in the subtypes has been re-examined by steady-state modelling of the relative outputs of the three enzymic products, uridine monophosphate, urinary orotic acid and urinary orotidine. It is shown that the ratio of urinary outputs of orotidine to orotate provides a means of testing for particular forms of enzyme defect. It is confirmed that the type I defect is caused by loss of uridine monophosphate synthase activity. Cells and tissue of type I cases have a residual amount of activity that is qualitatively unchanged: the relative rates of the transferase and decarboxylase do not differ from those of wild-type enzyme. The single claimed case of type II, thought to be due to specific inactivation of orotidine monophosphate decarboxylase, is shown to have a product spectrum inconsistent with that claim. It is proposed that this type II form does not differ sufficiently to be accepted as separate from type I. The third subtype, hereditary orotic aciduria without megaloblastic anaemia, occurs in two cases. It has the product spectrum expected of a defect in orotidine monophosphate decarboxylase. This form is the only one that appears to have a qualitatively different uridine monophosphate synthase. The possibility that orotidine monophosphate may control flux through the pyrimidine biosynthesis pathway in hereditary orotic aciduria is discussed.

Oral manifestations of vitamin B12 deficiency: a case report

Megaloblastic anemias are a subgroup of macrocytic anemias, in which distinctive morphologic abnormalities occur in red cell precursors in bone marrow, namely megaloblastic erythropoiesis. Of the many causes of megaloblastic anemia, the most common are disorders resulting from cobalamin or folate deficiency. The clinical symptoms are weakness, fatigue, shortness of breath and neurologic abnormalities. The presence of oral signs and symptoms, including glossitis, angular cheilitis, recurrent oral ulcer, oral candidiasis, diffuse erythematous mucositis and pale oral mucosa offer the dentist an opportunity to participate in the diagnosis of this condition. Early diagnosis is important to prevent neurologic signs, which could be irreversible. The aim of this paper is to describe the oral changes in a patient with megaloblastic anemia caused by a dietary deficiency of cobalamin.

Imerslund-Grasbeck syndrome: association with diabetes mellitus

A 14 year male adolescent born of 2nd degree consanguineous marriage presented with asymptomatic proteinuria and severe anemia. He had leucopenia, anisopoikilocytosis, megaloblastic erythropoiesis, megakaryocytes with low serum B12 level. His younger sibling was similarly affected. This combination suggested Imerslund-Grasbeck syndrome. The hemoglobin levels improved with injection of vitamin B12 but proteinuria persisted. During follow-up, he developed ketoacidosis due to insulin dependent diabetes mellitus. This rare combination has not been reported in the Indian literature.

Thiamine responsive megaloblastic anemia syndrome

Thiamine responsive megaloblastic anemia syndrome (TRMA) is a clinical triad characterized by thiamine-responsive anemia, diabetes mellitus and sensorineural deafness. We report a 4-year-old girl with TRMA whose anemia improved following administration of thiamine and this case report sensitizes the early diagnosis and treatment with thiamine in children presenting with anemia, diabetes and deafness.

Unusual case of thiamine responsive megaloblastic anemia

BACKGROUND

Thiamine-responsive megaloblastic anemia syndrome is a rare autosomal recessive disorder defined by the occurrence of megaloblastic anemia, diabetes mellitus, and neurosensoriel deafness, responding in varying degrees to thiamine treatment.

AIM

Report an unusual case of this rare disorder

CASE REPORT

We report the case of a four-year-old boy who presented unusual features of thiamine-responsive megaloblastic anemia. In addition to the typical triad of the syndrome, he presented leuconeutropenia, hepatosplenomegalia, cardiac abnormalities including absent P waves, mitral and tricuspid insufficiency, retinitis pigmentosa, nystagmus, developmental delay and a brain Magnetic resonance imaging ischemic lesion. Lactate levels in serum and the lactate/pyruvate ratio were increased. The mitochondrial mutation m.3243A > G located in MTTL1 gene encoding for transfer RNA leucine (tRNALeu(UUR)) was not found. Treatment with thiamine resulted in normalisation of the haemoglobin level, white cell count, and glucose and lactate levels. On three years follow up, the patient did not need insulinotherapy.

CONCLUSION

These data sign the crucial role that thiamine plays for many cells and tissues and its importance in the activity of the respiratory chain.

Combined megaloblastic and immunohemolytic anemia associated--a case report

A 55-year-old female with a history of psychosis and rheumatoid arthritis was admitted to the hospital for fatigue and dizziness. At admission, macrocytic anemia, high serum lactic acid dehydrogenase (LDH) and gastrin concentrations, decreased serum vitamin B12 concentration, with macroovalocytes and poikilocytes in peripheral blood smear suggested the diagnosis of pernicious anemia. Indirect antiglobulin test (IAT) was negative. Surprisingly, treatment by vitamin B12 and folic acid administered for two weeks was ineffective and followed by transitory worsening of hemoglobin concentration on day 8. Repeat direct antiglobulin test (DAT) and IAT were positive. This immunotransfusion conversion, suggesting the presence of autoimmune hemolytic anemia, could be explained by change in the macroblastic erythrocyte population, i.e. emerging red cells with completely exposed membrane antigens due to vitamin B12 treatment and/or higher degree of dysregulation of the lymphocyte clone secreting erythrocyte autoantibodies. We proposed the coexistence of pernicious and autoimmune hemolytic anemia; therefore, methylprednisolone was added to vitamin B12 treatment. This therapy successfully improved hemoglobin and erythrocyte concentration. Although megaloblastic-pernicious anemia is a common disease, association of pernicious and autoimmune hemolytic anemia with two mechanisms of hemolysis (ineffective erythropoiesis and immune mechanism) is a rare condition, with only several dozens of cases described so far.

[Floppy baby with macrocytic anemia and vegan mother]

We report the case of a 7 month-old girl that presented with acute anemia, generalized muscular hypotonia and failure to thrive. Laboratory evaluation revealed cobalamin deficiency, due to a vegan diet of the mother. The clinical triad of an acquired floppy baby syndrome with megaloblastic anemia and failure to thrive is pathognomic for infantile cobalamin deficiency. Neurological abnormalities are often irreversible and may be associated with delayed myelinization in the MRI. A normal cobalamin level in maternal serum and absence of anemia do not exclude subclinical deficiency. If cobalamin deficiency is suspected, e.g. in pregnant women on vegan diet, urinary methylmalonic acid excretion and plasma homocysteine levels should be determined and cobalamin substitution should be started at an early stage to avoid potentially irreversible damage of the fetus.

Imerslund-Grasbeck syndrome associated with recurrent aphthous stomatitis and defective neutrophil function

Vitamin B(12) deficiency is a well-known cause of recurrent aphthous stomatitis (RAS). However, the mechanism by which this deficiency causes the stomatitis is not well understood. Imerslund-Grasbeck syndrome (IGS) causes vitamin B(12) deficiency and proteinuria due to a defect in the vitamin B(12) receptor. We sought to determine whether the RAS observed in IGS patients is associated with neutrophil dysfunction. We report 3 infants with vitamin B(12) deficiency due to IGS, who presented with borderline or normal hemoglobin concentrations, RAS, and a neutrophil function defect. All 3 patients were homozygous for a splice site mutation affecting exon 4 of the AMN gene. A direct correlation was observed between low serum vitamin B12 levels and defective neutrophil function (low chemotaxis and elevated superoxide production) in the patients. Vitamin B(12) therapy led to an immediate resolution of aphthous stomatitis and full correction of neutrophil function. We demonstrated that serum vitamin B(12) deficiency is associated with a neutrophil chemotactic defect and RAS in IGS patients. We suggest that the RAS observed in these patients is due to this defect.

Dorsal sural nerve conduction study in vitamin B12 deficiency with megaloblastic anemia

Peripheral neuropathy is frequently observed in B(12) deficiency. In spite of this, there is little knowledge about peripheral neuropathy in B(12) deficiency because the severity of clinical involvement of the central nervous system clearly outweighs signs and symptoms due to peripheral nervous system involvement. We primarily investigated peripheral neuropathy with dorsal sural conduction study, which is a new method for detection of early peripheral neuropathy, in B(12) deficiency with megaloblastic anemia. Conventional nerve conduction studies and tibial sensory-evoked potential (SEP) recording were also performed. Twenty-eight B(12)-deficient patients (15 male, 13 female, mean age 65.8 years) with megaloblastic anemia and 18 age- and sex-matched controls were included in the study. Although dorsal sural sensory nerve action potentials (SNAPs) were not recorded in 15 (54%) of 28 patients, only 9 (32%) of them were found to have polyneuropathy by conventional conduction studies. Furthermore, patients with dorsal sural SNAP had mean lower amplitude, mean longer latency, and slower velocity response when compared with controls. Twenty patients (71%) were diagnosed as having myelopathy by the combination of tibial SEP and neurological findings. Two patients whose dorsal sural SNAPs were not recorded had normal tibial SEP responses; therefore, these patients were considered to have isolated peripheral neuropathy. As a result, we conclude that dorsal sural nerve conduction study is a reliable method for detection of early peripheral neuropathy in B(12) deficiency.

Localized gastric amyloidosis: a case report

Local deposition of amyloid without systemic involvement is rather uncommon and has been found in many organs. A 67-year- old man was admitted to our hospital presenting with weight loss, fatigue and poor appetite. Blood work and bone marrow examination revealed megaloblastic anemia. Upper gastrointestinal endoscopy reveeled e purple polypoid wass lesion of 5mm eliameter in the paracardiac region. Histopathologic examination of the gastric biopsy showed the deposition of amyloid materials in the mucosa. The patient had no evidence suggesting systemic amyloidosis. We report a rare case of localized amyloidosis of the stomach. The clinical and pathological features of this rare condition and association with megaloblastic anemia are discussed.

Steroid-responsive functional B12 deficiency in association with transcobalamin II polymorphism 776CG

We present a case of intracellular vitamin B12 deficiency presenting with confusion, subacute combined degeneration of the cord, megaloblastic anaemia and intrinsic factor antibodies in the serum. Diagnosis was delayed by a normal serum B12 level and was confirmed by a grossly elevated serum homocysteine. There was a dramatic response to steroids. The patient was heterozygous for the transcobalamin (TC) II polymorphism 776C --> G. This case demonstrates the importance of functional assessment of intracellular B12 activity (e.g. serum homocysteine) in excluding B12 deficiency, the role of steroids in pernicious anaemia and a possible clinical correlation of a TCII polymorphism.

[Belated decompensation of an Imerslund-Grasbeck disease]

Imerslund-Gräsbeck disease is an autosomic recessive disease characterised by a megaloblastic anemia due to a vitamin B12 deficiency and by a moderate proteinuria without kidney failure. It is caused by the malabsorption of Cobalamin-intrinsic factor complex bringing into play cubulin and other proteins (megaline, amnioless), some mutations of which are described at present. We report herein the observation of a child whose diagnosis was made belatedly during an acute decompensation with biological hemophagocytic syndrome. Its evolution was marked by the appearance of neurological disorders at the beginning of the vitamin B12 substitution treatment. These disorder regressed as the dosage was increase. The purpose of this observation is to recapitulate the main characteristics of this disease and to review the current data.

Anaphylactic reaction after intramuscular injection of cyanocobalamin (vitamin B12): a case report

We report a case of anaphylactic reaction to intramuscular injection of cyanocobalamin. This 52-year-old lady was diagnosed as a case of megaloblastic anemia secondary to dietary vitamin B12 deficiency. She had severe anaphylactic reaction after the parenteral administration of cyanocobalamine. Later she received oral vitamin B12 with no adverse effects. The purpose of this case report is to draw attention to the hypersensitive reaction to injectable vitamin B12, which is rarely seen. This could be due to sensitization to the vitamin B12 molecule itself or an IgE mediated reaction. We concluded that anaphylactic reaction to vitamin B12 is a rare but serious side effect and it should be kept in mind while the drug is being administered to the patient, especially via the parenteral route.

[Histological changes of the distal ileum in chronic diarrhea associated with megaloblastic anaemia]

Histological changes of the distal ileum were evaluated in thirteen (13) patients suffering from chronic diarrhea associated with Megaloblastic Anaemia (MA). The patients were seven (7) men and six (6) women with an average age of 55.6 (34-74). They were all diagnosed with MA and treated with cianocobalamin and folic acid, which resulted in fast recovery. Follow up on the patients did not show any other cause related to chronic diarrhea. Biopsies from the distal ileum were taken by colonoscopy. Endoscopy findings were not relevant except for a light paleness or slightly-rough mucose. The following changes were found by examining the histological radiographies: chronic inflammatory infiltration 92% (12), intestinal villous atrophy 62% (8), erosions at villous surface 46% (6), slight ectasia of the lymphatics 46% (6), flattening of the epithelium cells of the villous 38% (5), and focal fibrosis 38% (5). The patients suffering chronic diarrhea associated with MA showed significant changes of the distal intestinal mucose (ileum). Those changes are probably also in the surrounding area and could explain not only the chronic diarrhea, but the poor absorption observed on some of the patients. The quick response to cobalamins and folates treatment showed the important role of these elements in intestinal restoration.

Mitochondrial DNA deletion in a child with megaloblastic anemia and recurrent encephalopathy

A 3 1/2-year-old boy presented with megaloblastic anemia and recurrent episodes of severe lactic acidosis and coma. At age 4 years, he developed sepsis and died; postmortem examination failed to show any gross abnormality in any tissue. Biochemical analysis of muscle showed decreased activities for all respiratory chain enzymes except complex II. Muscle histochemistry revealed diffuse cytochrome c oxidase deficiency. Southern blot analysis of mitochondrial DNA from muscle, liver, and blood showed a heteroplasmic single mitochindrial DNA deletion of 2.4 kb, which removed the genes for cytochrome c oxidase I and II and the transfer ribonucleic acid genes for serine and aspartic acid. Single large-scale deletions in mitochondrial DNA have been associated with Pearson's syndrome, Kearns-Sayre syndrome, and progressive external ophthalmoplegia. This patient's presentation is unusual and suggests an overlap between Pearson's syndrome and Kearns-Sayre syndrome.

Disruption of transport activity in a D93H mutant thiamine transporter 1, from a Rogers Syndrome family

Rogers syndrome is an autosomal recessive disorder resulting in megaloblastic anemia, diabetes mellitus, and sensorineural deafness. The gene associated with this disease encodes for thiamine transporter 1 (THTR1), a member of the SLC19 solute carrier family including THTR2 and the reduced folate carrier (RFC). Using transient transfections into NIH3T3 cells of a D93H mutant THTR1derived from a Rogers syndrome family, we determined the expression, post-translational modification, plasma membrane targeting and thiamine transport activity. We also explored the impact on methotrexate (MTX) transport activity of a homologous missense D88H mutation in the human RFC, a close homologue of THTR1. Western blot analysis revealed that the D93H mutant THTR1 was normally expressed and underwent a complete N-glycosylation. However, while this mutant THTR1 was targeted to the plasma membrane, it was completely devoid of thiamine transport activity. Consistently, introduction into MTX transport null cells of a homologous D88H mutation in the hRFC did not result in restoration of MTX transport activity, thereby suggesting that D88 is an essential residue for MTX transport activity. These results suggest that the D93H mutation does not interfere with transporter expression, glycosylation and plasma membrane targeting. However, the substitution of this negatively charged amino acid (Asp93) by a positively charged residue (His) in an extremely conserved region (the border of transmembrane domain 2/intracellular loop 2) in the SLC19 family, presumably inflicts deleterious structural alterations that abolish thiamine binding and/or translocation. Hence, this functional characterization of the D93H mutation provides a molecular basis for Rogers syndrome.

[Association between subacute combined degeneration, vitamin B12 deficiency and megaloblastic anemia]

OBJECTIVE

To investigate the association between subacute combined degeneration (SCD) and vitamin B(12) (VB(12)) deficiency and megaloblastic anemia (MA).

METHODS

The serum level of VB(12), severity of anemia and lesions in CNS were analysed in 36 cases diagnosed as SCD. In addition, MRI neuro-electrophysiologic examination and CSF myelin basic protein (MBP) concentration were monitored dynamically. The prognosis of SCD was evaluated in relation to the time of the initiation of therapy.

RESULTS

Average ferrohemoglobin level in patients was (77.1 +/- 11.2) g/L and the average blood serum level of VB(12) was (87.0 +/- 21.4) ng/L before treatment with an abnormality rate of 47.2%. However, there was no linear correlation between the severity of lesions in CNS and ferrohemoglobin level or level of serum VB(12) (correlation coefficient: r = -0.1917, 0.0926, P > 0.5; r = 0.207, 0.101, P > 0.5, respectively). The comprehensive abnormal rate of evoked potential was 100%, which might occur prior to the clinical symptoms of SCD. The abnormal rate of MRI was 71.4%, and some lesions could diminish or disappear after treatment. The MBP levels in CSF were (3.96 +/- 1.66) ng/L, and (2.25 +/- 1.66) ng/L before and 3 months after the treatment. No significant improvement of symptoms and signs were seen when the treatment was initiated 6 months after the diagnosis.

CONCLUSION

SCD is associated with VB(12) deficiency and often accompanied by MA, but there is no linear correlation. Lesions of SCD in spinal cord or brain can be demonstrated in MRI. Evoked potential is critical for early diagnose and identification of silent cases of SCD. The level of MBP in CSF can reflect the severity of the lesion and prosthetic state of myelin sheath. Early diagnosis and treatment play an important role in decreasing the degree of the permanent dysfunction of CNS in SCD.

Patterns of pancytopenia patients in a general medical ward and a proposed diagnostic approach

BACKGROUND

There has been little systematic study on the clinical spectrum of pancytopenia. This study was done to describe the etiology, presentation and outcome of patients with pancytopenia presenting in a general medical ward.

METHODS

Hundred patients with pancytopenia were included in the study from October 2001 to October 2002. Patients on cancer chemotherapy were excluded. Blood counts, bone marrow examinations and trephine biopsies were performed according to standard methods.

RESULTS

In all cases, megaloblastic anemia constituted the largest group (n = 39), and also seen in conjunction with hemolytic anemia and septicemia. Hypersplenism secondary to portal hypertension (cirrhosis) was the second most common diagnosis (n = 19). Aplastic anemia, septicemia and myelodysplasia were other common causes. Two patients were the suspected cases of viral hemorrhagic fever. Thirteen (13%) patients expired. Absolute neutrophil count (ANC) less than 500/microliter was seen in 14 (14%) patients, among which 6 (15.3%) had megaloblastic anemia, 3 (37.5%) had aplastic anemia, and 2 (40%) had myelodysplasia. Eleven patients with platelet counts < or = 10 x 10(9)/L, 6 (54.5%) presented with bleeding; and 2 of these 8 had aplastic anemia and 1 patient with megaloblastic anemia. MCV values > 100 fL and > 110 fL were more frequent in patients with megaloblastic anemia with most prominent anisopoikilocytosis, microcytosis and fragmented RBCs. Macrocytosis was noted in 35 (89.7%) patients with megaloblastic anemia and 12 (63.1%) with hypersplenism, 4 (50%) with aplastic anemia. Hypersegmented neutrophils were noted in the blood films of 36 (92.3%) patients with megaloblastic anemia.

CONCLUSION

Megaloblastic anemia, hypersplenism and aplastic anemia are the common causes of pancytopenia in our study.

The aetiology of severe anaemia among antenatal patients of the Port Moresby General Hospital

Between October 1998 and September 2000, 111 consecutive pregnant patients admitted to the Port Moresby General Hospital antenatal ward with a haemoglobin level of 6 g/dl or less were studied. The main causes of the severe anaemia were as follows: iron deficiency on its own or in combination with another factor 66%--iron deficiency on its own 43% and combined folate and iron deficiency 23%--and folate deficiency 18%. Malaria was a contributory factor in 13 patients (12%). A combination of blood film, bone marrow study, serum assays of ferritin, folate and vitamin B12, and mean corpuscular volume (MCV) was used to determine the cause of the anaemia. Ferritin levels on their own poorly correlated with the presence of iron in the bone marrow. A low MCV correlated well with iron deficiency anaemia while a high MCV was associated with folic acid deficiency. It would seem therefore that while a bone marrow study is mandatory to reach a definitive diagnosis of severe anaemia, MCV, in conjunction with the red cell morphology on blood film, would be a good marker for iron and folic acid deficiency anaemia, especially as we do not have serum assays readily available for folate, ferritin and vitamin B12 in Papua New Guinea.

Cardiac manifestations in thiamine-responsive megaloblastic anemia syndrome

Thiamine-responsive megaloblastic anemia (TRMA) syndrome is a rare autosomal recessive disorder defined by the occurrence of megaloblastic anemia, diabetes mellitus, and sensorineural deafness, responding in varying degrees to thiamine treatment. Other features of this syndrome gradually develop. We describe three TRMA patients with heart rhythm abnormalities and structural cardiac anomalies. Eight other reported TRMA patients also had cardiac anomalies. Recently, the TRMA gene, SLC19A2, was identified, encoding a functional thiamine transporter. Characterization of the metabolic defect of TRMA may shed light on the role of thiamine in common cardiac abnormalities.

[A case of subacute combined degeneration with normal serum vitamin B12 level]

A 40-year-old woman was admitted to our hospital because of pancytopenia with megaloblastic anemia. Two months later she complained of rapidly progressive gait disturbance and numbness in the distal part of limbs. She also told that her hair had turned totally gray in the third decade. Neurologically, mental state, cranial nerves and cerebellar functions were normal. Superficial sensations were impaired below the lower thoracic level and deep sensations were completely lost in the lower limbs. Moderate weakness was found in the lower limbs, symmetrically. Deep tendon reflexes were diminished in the upper limbs and absent in the lower limbs. Babinski's reflex was positive bilaterally. MR images of the spinal cord showed hyperintensity in the posterior column below the thoracic cord. Although the serum level of vitamin B12 was within normal range, serum homocysteine level was elevated markedly. Under the diagnosis of subacute combined degeneration (SCD) due to possible vitamin B12 deficiency, the treatment with intravenous injections of 500 micrograms/day of mecobalamin was undertaken. Muscle strength and sensory impairment improved progressively and she became able to walk with a cane. The coloration of her gray hair was also noted. After treatment, pancytopenia and megaloblastic anemia also markedly improved. Vitamin B12 became high in serum concentration and the serum level of homocysteine became normal. These clinical and laboratory findings support the diagnosis of SCD with normal serum level of vitamin B12 in our case, suggesting that the level of vitamin B12 in serum does not always correlate with that in tissue and, therefore, SCD should not be excluded just only by the reason of normal serum vitamin B12 level.

[Chorea in hemodialysis: Is chorea just a neurological syndrome or is it related to uremia or dialysis?]

Chronic renal failure and haemodialysis patients are prone to develop encephalopathy. The causes of encephalopathy are often unclear. Clinical signs of encephalopathy in the uraemic patient often overlap with several other affections causing neurological disorders. Whenever basal ganglia are anatomically involved, movement disorders arise, including chorea. Some acute and chronic neurological syndromes associated with chronic uraemia have consistently been reported (uraemic encephalopathy, dialysis disequilibrium syndrome, dialysis dementia, nephroangiosclerosis neuropathy and ageing neuropathy). Other clinical conditions in which neurological involvement exists are not so frequent in both haemodialysis patients and in the general population (Wernicke's encefalopathy, Creutzfeldt-Jacob disease). Because of the non specific symptoms and the very heterogeneous aetiology, a careful physical examination should be performed in haemodialysis patients with clinical signs of encephalopathy and the main metabolic alterations should be sought; moreover, central nervous system imaging examination is often appropriate. In case of basal ganglia anatomical involvement, supported by findings of imaging techniques, it is necessary to evaluate individual causes of encephalopathy by means of more accurate tests including analysis of cerebro-spinal fluid, measurement of plasma levels of vitamin B components and laboratory tests searching for more uncommon diseases such as Huntington's chorea and Wilson's disease.

Benefits and risks of folic acid to the nervous system

During three decades of neurological practice I have witnessed a remarkable change in attitudes to the benefits and risks of folic acid therapy in nervous system disorders. In the 1960s all that was known and taught was that folic acid was harmful to the nervous system, especially in precipitating or exacerbating the neurological complications of vitamin B12 deficiency. So deeply held was this view that the possibility of neuropsychological benefits from this vitamin was initially viewed with considerable scepticism.

Generalized hyperpigmentation of the skin due to vitamin B12 deficiency

A 49-year-old man presented with neurosis, hyperpigmentation of the skin, and depigmentation of the hair. On examination, hyperpigmentation was observed on the oral mucosa and the skin of the forearms, elbows, palmar creases and periunguinal area, knees, and feet. He had megaloblastic anemia with a low serum level of vitamin B12 due to malabsorption resulting from a gastrectomy 10 years previously. His hyperpigmentation was resolved with vitamin B12 supplementation. Histology showed an increase of melanin in the basal layer. In electron microscopic study, many melanosomes were observed in melanocytes and surrounding keratinocytes. We consider that the dominant mechanism of hyperpigmentation due to vitamin B12 deficiency is not a defect in melanin transport but is rather an increase in melanin synthesis.

Transient splenic accumulation of Tc-99m HMDP caused by megaloblastic anemia

A case of transient splenic accumulation of the bone-seeking agent Tc-99m HMDP is reported. This effect was caused by transient megaloblastic anemia induced by 5-fluorouracil chemotherapy. The extent of splenic uptake reflected the development and severity of megaloblastic anemia. The mechanism of splenic accumulation is thought to be similar to transient iron deposition in the spleen by megaloblastic anemia.

Etiology and diagnostic evaluation of macrocytosis

BACKGROUND

Elevation of mean cell volume (MCV) is a common clinical problem, but the etiologic spectrum and optimal diagnostic evaluation of macrocytosis are not well defined.

METHODS

We studied 300 consecutive hospitalized adult patients with MCV values > or = 100 fL. Assessment included complete blood counts, morphologic review, liver function tests, and levels of serum cobalamin (Cbl), methylmalonic acid, and total homocysteine.

RESULTS

The most common cause of macrocytosis was drug therapy, followed by alcohol, liver disease, and reticulocytosis. Megaloblastic hematopoiesis accounted for less than 10% of cases. MCV values > 120 fL were usually caused by Cbl deficiency. Anisocytosis, macro-ovalocytosis, and teardrop erythrocytes were most prominent in megaloblastic hematopoiesis. Elevated levels of serum methylmalonic acid and total homocysteine were useful in the diagnosis of Cbl deficiency.

CONCLUSIONS

Drugs and alcohol are the most common causes of macrocytosis in hospitalized patients in a New York City teaching hospital. We have formulated tentative guidelines for the evaluation of high MCV values in this setting.